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Tonsillectomy in children

03.01.2011
A multidisciplinary clinical practice guideline, "Tonsillectomy in Children" will be published in the January issue of Otolaryngology—Head and Neck Surgery (watch for a new cover and publisher in that issue of the journal).

The new guideline provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children aged 1 to 18 years under consideration for tonsillectomy. Additionally, this guideline is intended for all clinicians in any setting who care for these patients. This guideline also addresses practice variation in medicine and the significant public health implications of tonsillectomy.

Tonsillectomy is one of the most common surgical procedures in the United States, with over 530,000 procedures performed annually in children under 15 years old. Tonsillectomy is defined as a surgical procedure (performed with or without adenoidectomy) that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Depending on the context in which it is used, the term may indicate tonsillectomy with adenoidectomy, especially in relation to sleep-disordered breathing.

"Over half a million tonsillectomies are done every year in the United States," said Richard M. Rosenfeld, MD, MPH, journal guideline author and consultant. "The tonsillectomy guideline will empower doctors and parents to make the best decisions, resulting in safer surgery and improved quality of life for children who suffer from large or infected tonsils."

The primary purpose of this guideline is to provide clinicians with evidence-based guidance in identifying children who are the best candidates for tonsillectomy. Secondary objectives are to optimize the perioperative management of children undergoing tonsillectomy; emphasize the need for evaluation and intervention in special populations; improve counseling and education for families of who are considering tonsillectomy for their child; highlight the management options for patients with modifying factors; and to reduce inappropriate or unnecessary variations in care.

Otolaryngology – Head and Neck Surgery is the official scientific journal of the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF).

The study's authors are Reginald Baugh, MD; Sanford Archer, MD; Ron Mitchell, MD; Richard M. Rosenfeld, MD, MPH; Raouf Amin, MD; James Burns, MD; David Darrow, MD, DDS; Terri Giordano, MSN; Ronald Litman, DO; Kasey Li, MD, DDS; Mary Ellen Mannix, MRPE; Richard H. Schwartz, MD; Gavin Setzen, MD; Ellen R. Wald, MD; Eric Wall, MD, MPH; Gemma Sandberg, MA; and Milesh M. Patel, MS. The guideline panel authors were chosen to represent fields of sleep medicine, advanced practice nursing, anesthesiology, infectious disease, family medicine, otolaryngology–head and neck surgery, pediatrics, and consumers.

About the AAO-HNS

The American Academy of Otolaryngology – Head and Neck Surgery (www.entnet.org), one of the oldest medical associations in the nation, represents nearly 12,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The organization's vision: "Empowering otolaryngologist-head and neck surgeons to deliver the best patient care."

Important Points about the AAO-HNS Tonsillectomy Guideline

What is tonsillectomy and why is it important?

Tonsillectomy is the third most common surgery (after circumcision and ear tubes) performed on children in the United States, with over 530,000 annual procedures (1 in 7 ambulatory surgeries under age 15 years).

Tonsillectomy removes two walnut-sized masses from the back of the throat, most often for frequent throat infections or obstructed breathing when asleep (sleep-disordered breathing, or SDB).

When performed in properly selected children, tonsillectomy can reduce throat infections, doctor visits, and antibiotic use, and can improve a child's quality of life, daytime functioning, and ability to sleep soundly.

Despite the frequency of tonsillectomy, until now there have been no evidence-based national guidelines to assist doctors in providing the highest quality care and help children recover safely and rapidly.

Why is the Tonsillectomy Guideline newsworthy?

It is the first – and only - national, evidence-based guideline on tonsillectomy in the United States.

President Obama highlighted tonsillectomy in a September 2009 address on healthcare reform

It was created by a multidisciplinary panel, including consumers, representing nursing, pediatrics, family medicine, otolaryngology – head and neck surgery, anesthesiology, sleep medicine, and infectious disease.

In an era of comparative effectiveness research, well-crafted guidelines help improve quality, promote optimal outcomes, minimize harm, and reduce inappropriate variations in care.

What is the purpose of the Tonsillectomy Guideline?

To help clinicians identify children who are the best candidates for tonsillectomy (and those who are not)

To optimize the before-and-after care of children undergoing tonsillectomy

To improve counseling and education of families who are considering tonsillectomy for their child.

What are the newsworthy points made in the Guideline?

Most children with frequent throat infection get better on their own; watchful waiting is best for most children with less than seven episodes in the past year, five a year in the past two years, or three a year in the past three years.

Severe throat infections are those with fever of 101 or higher, swollen or tender neck glands, coating (exudate) on the tonsils, or a positive test for strep throat.

Tonsillectomy can improve quality of life and reduce the frequency of severe throat infection when there are at least seven well-documented episodes in the past year, five a year in the past two years, or three a year in the past three years.

Children with less frequent or severe throat infections may still benefit from tonsillectomy if there are modifying factors, including antibiotic allergy/intolerance, a history of peritonsillar abscess (collection of pus behind the tonsil), or PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis).

Large tonsils can obstruct breathing at night, causing sleep-disordered breathing (SDB), with snoring, mouth breathing, pauses in breathing, and sometimes sleep apnea (pauses more than 10 seconds).

Doctors should ask parents of children with SDB and large tonsils about problems that might improve after tonsillectomy, including growth delay, poor school performance, bedwetting, and behavioral problems.

Although most children with SDB improve after tonsillectomy, some children, especially those who are obese or have syndromes affecting the head and neck (e.g., Down), may require further management.

Doctors should give a single, intravenous dose of dexamethasone (a steroid medicine) during tonsillectomy to reduce pain, nausea, and vomiting after surgery.

Doctors should not routinely prescribe antibiotics to improve recovery following tonsillectomy surgery, because medical studies show no consistent benefits over placebo and there are associated risks and side effects.

Doctors should educate parents about the importance of managing and reassessing pain after tonsillectomy. Strategies include drinking plenty of fluids, using acetaminophen or ibuprofen for pain control, giving pain medicine early and regularly, and encouraging their child to tell them if their throat hurts.

Mary Stewart | EurekAlert!
Further information:
http://www.entnet.org

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